PO BOX 3867, Bellevue, WA P: I F: ROOFERS APPLICATION (COMPLETE IN ADDITION TO GL APPLICATION)

Transcription

1 PO BOX 3867, Bellevue, WA P: I F: submissions@gogus.com ROOFERS APPLICATION (COMPLETE IN ADDITION TO GL APPLICATION) Applicant s Name: Mailing Address: Agency Name: Agent No.: Address: Location Address: Website Address: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE (N/A) 1. What percentage of your work is residential (homes, condominiums)?... % What percentage of your work is commercial (office buildings, schools, retail establishments)?... % What percentage of your work is industrial (plants, warehouses)?... % TOTAL: 100% 2. Type of Roofing Operation Residential Commercial Industrial Percentage of Total Operations What percentage of work is New Construction? % % % % What percentage of work is Repair/Patching? % % % % What percentage of work is Replacement? % % % % Total: 100% 100% 100% 100% What percentage of work is on Pitched Roofs? % % % % What percentage of work is on Flat Roofs? % % % % Total: 100% 100% 100% 100% GLS-8 (9-16) Page 1 of 6

2 Indicate type of work performed and percentage of operations within Type of Roofing Operation Residential Commercial Industrial Percentage of Total Operations Shingles/Shakes: Asphalt % % % % Fiberglass % % % % Wood % % % % Concrete % % % % Slate % % % % Metal % % % % Shingle Ply % % % % Tile % % % % Polyurethane Foam: Sheet Form % % % % Sprayed % % % % Hot Tar and/or Asphalt/Built up % % % % Rubber/Elastomerics % % % % Other (describe): % % % % Total: 100% 100% 100% 100% 3. Check work done other than roofing: Waterproofing Siding Asbestos removal Rain gutters Carpentry Insulation Other (describe): 4. If hot tar, torch or other hot process is used, explain in detail the process and what safety precautions are used: 5. Do you subcontract any work?... Yes No If yes, what percentage do you subcontract?... % 6. Check the type of work subcontracted out: Waterproofing Siding Hot tar Rain gutters Carpentry Insulation Other (describe): 7. What is the annual cost of the work subcontracted out?... $ yearly 8. Are Certificates of Insurance (of equal limits) received on all subcontracted work?... Yes No 9. How long are Certificates of Insurance kept? Until job ends One year Two years Three years More than three years Never kept 10. Do you utilize day laborers?... Yes No If yes, how many within a year?... GENERAL INFORMATION 11. List any roofing/builder associations in which you are a member: GLS-8 (9-16) Page 2 of 6

3 12. Receipts, Payroll and Number of Employees for previous three years: Year Receipts Payroll $ $ $ $ $ $ No. of Full-Time Employees No. of Part-Time Employees 13. Do you offer warranties?... Yes No If yes, attach copies of warranty. 14. What is the average height of buildings you work on?... stories 15. What is the tallest building you will work on?... stories 16. Where do you dispose of trash/waste/scraps? 17. Is this disposal process environmentally safe?... Yes No 18. Have you ever used, sold, installed or worked with asbestos?... Yes No If yes, explain: 19. Any LPG storage?... Yes No If yes, how much? How is it stored? What are the safety precautions? 20. List the five largest jobs and types in the last three years: Years of experience:... MATERIALS AND EQUIPMENT 22. List the type of owned equipment used on the job: GLS-8 (9-16) Page 3 of 6

4 23. List any equipment rented and check the frequency of such rental: Type of Equipment EQUIPMENT RENTED How often do you rent this equipment? Daily Weekly Monthly Yearly PUBLIC PROTECTION 24. Do you have a written safety program?... Yes No 25. How do you protect the general public from potential injury? Check one or more: Rope off work area Signs Cones Flashing lights Man always on the grounds No protection necessary Other (describe): 26. How are materials lifted to the roof? Ladder Hoist Pulley Crane Other (describe): 27. Are materials and equipment left overnight at job site?... Yes No 28. In what manner are openings in roof protected overnight? Tarp Waterproof plywood Never leave openings Other (describe): 29. What on-the-job precautions do you take when rained on? Leave job immediately Seal openings Keep on working Never start job Remarks (be specific): 30. Are all jobs inspected by a foreman or the contractor at completion before leaving the job site?... Yes No FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY, OH, OK, OR, RI, TN, VA, VT or WA.) NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. GLS-8 (9-16) Page 4 of 6

5 WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation. GLS-8 (9-16) Page 5 of 6

6 NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. APPLICANT S STATEMENT: I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kansas: This does not constitute a warranty.) APPLICANT S SIGNATURE: CO-APPLICANT S SIGNATURE: PRODUCER S SIGNATURE: AGENT NAME: IOWA LICENSED AGENT: DATE: DATE: DATE: AGENT LICENSE NUMBER: (Applicable to Florida Agents Only) (Applicable in Iowa Only) IMPORTANT NOTICE As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided. GLS-8 (9-16) Page 6 of 6